Assessment of knowledge among dental practitioners regarding digital dental record platform as a forensic aid for personal identification

Abstract

Background:

Forensic dentistry deals with handling, examination, and evaluation of dental records, which are also required for medicolegal purpose. Digital forensic science has revolutionised the traditional forensic investigation by development of software and digital records. This results in quick identification and allows extraction of a large amount of data with less bias. As the conventional forensic procedures are tedious and time-consuming, there is a need for a digital platform that may help registration of dental records of all patients.

Aim:

The study aims to assess the knowledge regarding Digital Dental Record Platform as a forensic aid for personal identification among the dental practitioners.

Methodology:

After validation of the prepared questionnaire, it was circulated digitally as a google form and manually among dental practitioners in Belagavi city. The results obtained were tabulated and statistically analysed.

Results:

94.4% respondents thought that there is a need for a centralised digital platform to maintain dental records in India and it will be useful if the Indian government links the centralised dental record database with Aadhaar (91.7%). 92.6% respondents were willing to be a part of program where dental records are updated to a centralised digital platform.

Conclusion:

India lacks a centralised digital platform as compared to western countries for forensic identification. Thus, there is a need for centralised digital dental record repository under Government of India which will be easily accessible for effective victim identification. A dentist plays a major role in this initiative as teeth and dental structures survive adverse conditions.

INTRODUCTION

Forensic dentistry plays an important role in identification of severely dismembered remains or decomposed bodies.[1] The need of identification using dental remains is on increase as natural calamities, mass disasters, and crimes are increasing.[2] Digital forensic science has revolutionised the traditional forensic investigation by development of software and digital records. This results in quick identification and extraction of a large amount of data with less sampling bias.[2]

As the conventional forensic procedures are tedious and time-consuming, there is a need of a digital platform that may help registration of dental records of all patients. Dentists’ primary responsibility is to register their practices with the Clinical Establishments Act of 2010.[3] Second, they must follow the procedures established by the government in maintaining the dental records digitally of every patient they are treating. This way, the dental records can be easily accessible in one digital platform that may be operated by a Government Agency[3]. It will be helpful in identification not only of an individual but also in mass disasters where dental teams are assisted by “Disaster Mortuary Operational Response Team” (DMORT), which is part of “National Disaster Medical Service” (NDMS).[4]

The involvement of DMORT and NDMS in forensic odontology is particularly significant for identifying victims in mass disasters.[5] As part of NDMS, DMORT plays a vital role in delivering specialized forensic, mortuary, and victim identification services during large-scale emergencies.[6] Their multi-disciplinary teams, including forensic odontologists, deoxy ribonucleic acid (DNA) experts, and anthropologists, are crucial for conducting accurate post-mortem identification using dental records.[7] In cases where visual or fingerprint identification is not feasible, dental evidence serves as a scientifically reliable method.[6] The collaboration between dental teams and DMORT enhances the precision and effectiveness of the identification process, ensuring victims are identified with greater accuracy.[5] Furthermore, NDMS provides a federally coordinated infrastructure, streamlining DMORT’s operations and enabling a rapid and organized response to national crises. This partnership highlights the essential role of forensic dentistry in mass disaster protocols, making DMORT and NDMS integral to victim identification and the dignified management of remains.[6,7]

Numerous studies regarding the role of forensic dentistry have already been published, and it is likely that most general dentists are familiar with forensic dentistry. Dentists must constantly self-reflect in order to respond to questions posed by general public, such as where they stand within the Disaster Victim Identification (DVI) team, when they are called, and why an odontologist is needed for victim identification.[8] Forensic dentistry relies on restorations, prosthetic devices, and missing teeth that may be easily documented in the record. Denture labelling with a special identifying feature like microchip, QR code, or barcode is an effective form of identity proof.[9]

The present study aims to assess the knowledge among dental practitioners regarding role of digital dental records in forensic dentistry.

METHODOLOGY

The study comprised a cross-sectional assessment using a questionnaire conducted within the Department of Oral and Maxillofacial Pathology and Microbiology, KLE VK Intistute of Dental Sciences, aimed gathering pertinent data. Approval from the institutional review board was secured to conduct the study (IEC no: 1612).

Prior to their participation in the study, all participators provided with informed consent. The questionnaire-based study comprised 14 questions that were validated and then distributed via google forms as well as hard copies among dental practitioners of Belagavi city. A preliminary study with 10 participants was undertaken to validate the questionnaire. Following this phase, these participants were excluded from the final study; no modifications were deemed necessary for the questionnaire. The questionnaire used dichotomous and multiple-choice questions. The sample for the study included the general dentists (practitioners), specialised dentists (practitioners), academicians, and postgraduate dental students, and those unwilling to participate were excluded. The study was conducted over a period of 2 months (December 2022 to January 2023). The collected information was updated on the Microsoft Excel spreadsheet followed by calculation of frequency and percentage with appropriate tables and graphs constructed.

OBSERVATIONS AND RESULT

Table 1 depicts the responses arranged according to question and the frequency distribution as per the 108 responses received via hard copies and Google Forms. The 108 responses were divided into three major parts consisting of demographic data, dental record maintenance, and their importance in forensic dentistry and centralising the records in the digital platform.

Table 1.

Question-wise responses of the participants

Questions	No of respondents	% of respondents
Are you?
General Practitioner	24	22%
Specialized Practitioner	20	18.5%
All of the above	5	4.6%
In private practice and/or in academics	56	51.8%
Not applicable	3	2.7%
How long are you into your job?
<5	83	76.8%
>20	6	5.5%
>5-10	4	3.7%
10-20	12	11%
Not applicable	2	1.85%
Do you maintain dental records of your patients?
Yes	95	87.9%
No	12	11.1%
Not applicable	1	0.9%
How do you maintain your patient record?
Software	16	14.8%
Hardcopy	22	20.3%
Both hard and soft copy	59	54.6%
Not applicable	11	10.1%
How long do you maintain patient records?
<1 year	47	43.5%
>5 year	15	13.8%
1-3 years	27	25%
3-5 years	17	15.7%
Not applicable	2	1.85%
Do you know about digital markings (QR coding) on dentures, fillings, implants, and crowns practised in India?
Yes	77	71.3%
No	31	28.7%

In our results, 51.8% of the respondents were in private practice and/or in academics with more than 5 years job experience (76.8%).

87.9% of the respondents responded that they maintain dental records for patients in both soft and hard copies (54.6%) for less than 1 year (43.5%). Our study also showed 96% respondents were aware of significance of maintaining dental records in identifying deceased in crimes and disasters and 100% respondents opined that as a dentist, we can help forensic experts by maintaining dental records [Figure 1a and b]. 71.3% respondents knew about digital markings (QR coding) on dentures, fillings, implants, and crowns practised in India, but only 26.8% in total use QR code/bar code (14%), microchip (2%), and identification band (7%) for method of identification for prosthesis/case paper/x-ray. 96.3% responded that maintaining patient records on a centralised digital platform will be helpful [Figure 1c and d]. 43.5% know that a centralised digital platform is used to maintain dental records followed in western countries, and 94.4% respondents think there is a need for a centralised digital platform to maintain dental records in India [Figure 2a and b]. 91.7% respondents think that it will be useful if the Indian government links a centralised dental record database with Aadhaar, and 92.6% respondents are willing to be a part of program where dental records are updated to a centralised digital platform [Figure 2c and d].

Figure 1.

(a) Pie chart regarding the awareness about significance of maintaining dental records. (b) Response related to how dentists can help forensic experts by maintaining dental records. (c) Methods of identification used by dentists. (d) Responses related to use of centralised digital platform

Figure 2.

(a) Pie chart depicting the response related to awareness regarding a centralised digital platform availability in western countries. (b) Need for a digital platform in India. (c) Responses for whether the digital platform should be linked to Aadhar database (d) Pie chart depicting the willingness to be part of a program to upload dental records in a central platform

DISCUSSION

Forensic odontologists have a specific purpose in “Disaster Victim Identification” (DVI) scenarios. Upon arrival at the disaster site, dental teams actively engage in all four phases of DVI: scene examination, post-mortem examination, ante-mortem data collection, and reconciliation.[10] Their involvement begins in the initial phase of DVI, as part of the recovery team, where they meticulously document dental evidence onsite before its removal. This proactive approach aims to prevent damage to fragile dental materials, especially in cases involving charred bodies, during transportation to the mortuary.[10,11] Subsequently, forensic odontologists help with identifying and documenting any displaced dental structures such as implants, dentures, or dental appliances at the scene. High-resolution images of these findings are captured for later comparison with ante-mortem dental records, ensuring accurate reconciliation and debriefing procedures.[11] This comprehensive approach underscores the importance of dental evidence in the identification process and highlights the critical role of forensic odontologists in preserving and documenting such evidence effectively at the scene of a disaster.[12]

So, we conducted the study among practitioners like general practitioners and specialised practitioners in private practices or in academics to evaluate the understanding of the Digital Dental Record Platform’s role as a forensic tool for personal identification among them. The maintenance of dental records aligns with principles of evidence-based practice, diagnostic accuracy, treatment monitoring, legal, ethical reasons, risk management, insurance claim, and research-driven healthcare.[13] By adhering to rigorous recordkeeping standards, dental professionals can optimise patient care, ensure compliance with regulatory requirements, and advance scientific knowledge in the field of dentistry.[14]

Digital dental records provide numerous scientific advantages across various dimensions including precision, data integrity, efficacy of time, interoperability, diagnostic capabilities, decision support, and security.[15] Through standardised data entry formats and advanced electronic storage mechanisms, these records ensure accuracy, reliability, and accessibility of patient information.[16] By seamlessly integrating with other healthcare systems, digital records facilitate communication and collaboration among healthcare providers, promoting care coordination and enhancing patient outcomes.[17] Our study also showed 95.3% respondents are aware of significance of maintaining dental records in identifying deceased in crimes and disasters and 100% respondents opined that as a dentist, we can help forensic experts by maintaining dental records. Additionally, 87.9% of the respondents maintain dental records for patients in both soft and hard copies.

After natural and man-made disasters, particularly mass casualties like aviation disasters, dental identification emerges as a critical tool in establishing the identities of victims. The investigative process begins with scene examination and documentation, capturing vital information through photography.[9] Subsequently, forensic odontologists conduct meticulous post-mortem dental examinations, utilising various techniques such as dental charting, radiographic imaging, and sometimes DNA analysis of biological specimens. These examinations aim to gather detailed data on dental characteristics and conditions of the victims’ remains.[9] Antemortem dental records, including charts, X-rays, and photographs obtained during routine dental visits, serve as crucial reference points for comparison.[9]

By meticulously comparing post-mortem findings with antemortem records, dentists can facilitate positive identifications or eliminate potential matches. This systematic approach, combining dental expertise and record keeping practices, plays a pivotal role in resolving mass casualty incidents, offering closure to affected families and communities.[9]

Our study also showed 95.3% respondents were aware of significance of maintaining dental records in identifying deceased in crimes and disasters and 100% respondents opined that as a dentist, we can help forensic experts by maintaining dental records. In India, the practice of incorporating digital markings on dental prosthetics, such as dentures, fillings, implants, and crowns, has been gaining traction in recent years.

Digital marking involves embedding unique identifiers, often in the form of barcodes, QR codes, identification bands, or microchips, onto dental prosthetics during the manufacturing process.[18,19,20] These digital markings serve as a means of tracking and tracing the prosthetics back to their origin and owner. Digital markings like QR codes stand out as the optimal choice for digital markings on dental prosthetics due to several compelling reasons.[18,19,20] Firstly, QR codes possess unmatched versatility, capable of encoding a wealth of information including manufacturer details, patient identifiers, material specifications, and production dates. This comprehensive data capacity ensures that crucial information about the dental prosthesis is readily accessible.[18] However, despite the numerous benefits QR codes offer for digital markings on dental prosthetics, their widespread adoption in routine practice faces several challenges, which include initial costs associated with equipment, software, and training, which may deter smaller practices with limited resources.[19] Additionally, integrating QR code scanning into existing workflows requires adjustments and staff training, while concerns about data privacy and security must be addressed with robust measures. Achieving uniform standardisation and patient acceptance also pose significant hurdles.[19] Moreover, regulatory compliance and varying levels of technological infrastructure further complicate adoption efforts. To promote widespread adoption, concerted efforts from dental professionals, technology providers, policymakers, and regulatory bodies are necessary to overcome these challenges and realise the potential benefits of QR code technology in dental practice.[19]

Thus, in this study, though 71.3% respondents know about digital markings (QR coding) on dentures, fillings, implants, and crowns practiced in India, only 26.8% use QR code/bar code, microchip, and identification band for method of identification for prosthesis/case paper/x ray.

In our study, 43.5% know that a centralised digital platform is used to maintain dental records followed in western countries and 96.3% responded that maintaining patient records on a centralised digital platform is helpful. Centralised digital platforms in Western countries such as Dentrix, Epic Systems, and Open Dental are prominent examples of practice management software systems that provide comprehensive solutions for scheduling, charting, billing, and treatment planning.[21,22]

Additionally, platforms like Dental XP, Dentistry IQ, and Dental Tribune offer valuable resources for continuing education, clinical insights, industry news, and professional networking opportunities.[23] These platforms are successful in Western countries due to their user-friendly interfaces, continuous innovation, high-quality content, community engagement, and industry recognition which serve as crucial antemortem data for comparison with post-mortem findings in forensic investigations.[23] Digital platforms further enhance dentist understanding and application of evidence-based approaches in practice.[23]

In India, numerous organisations like the “Indian Association of Forensic Odontology” (IAFO) and “Indo-Pacific Academy of Forensic Odontology” (INPAFO) are dedicated to enhancing the field.[24] Moreover, “IAFO” has instigated the “National Registry of Forensic Odontology”, encouraging dental institutions and practitioners throughout country to regularly update patient records, thus facilitating the establishment of a comprehensive nationwide repository.[24]

Thus, a centralised platform for dental records and forensic identification in India would streamline the identification process by providing easy access to comprehensive dental records nationwide. Arvind et al.[18] proposed a forward-thinking solution involving the utilisation of fingerprints through authorised standardisation testing and quality certification (STQC) Certified electronic devices linked to Aadhaar numbers for the identification of unidentified deceased individuals.

Aadhaar, serving as a digital identity, offers paperless and accessible identity verification anytime and anywhere throughout a resident’s lifetime. Identity verification occurs online through authentication devices connected to Unique Identification Authority of India (UIDAI’s) Central Identity Repository. These devices provide a simple ‘yes’ or ‘no’ response to the query “Is the person who they claim to be?” based on the information stored within UIDAI.[25] It is noteworthy that the Aadhaar authentication service is fully operational, ensuring reliable identity verification.[18] This aspect could be utilised to develop an Aadhar-based dental record system. It was observed that 94.4% respondents think there is a need for a centralised digital platform to maintain dental records in India and think it will be useful if the Indian government links the centralised dental record database with Aadhaar (91.7%). Each individual’s Aadhaar number serves as a unique identifier, linking them to their dental records stored in the centralised platform. This integration will ensure that dental records are accurately matched to the correct individual, reducing the risk of errors or misidentification. The Aadhaar-based dental record system would include detailed information such as dental charts, X-rays, treatment history, and demographic data. This comprehensive dataset will provide a holistic view of each patient’s oral health status and treatment needs. These dental records linked to Aadhaar numbers should securely store in a centralised database with stringent data security measures in place. Access to patient information should be strictly controlled and protected to maintain confidentiality and privacy. The incorporation of Aadhaar-linked dental records into a centralised system demands the implementation of rigorous data security protocols and a strong focus on ethical considerations to safeguard patient confidentiality. In order to protect sensitive information, the platform should employ advanced encryption standard (AES)-256 encryption to secure data both at rest and in transit, effectively preventing unauthorised access.[26] Furthermore, two-factor authentication (2FA), utilising biometric verification and password protection, should be mandatory to enhance security measures.[26,27,28]

Access to patient records must be controlled through Role-Based Access Control (RBAC), ensuring that only authorised individuals, such as forensic odontologists and dental practitioners, have access to specific data.[27] Routine security audits and penetration testing should be carried out to identify vulnerabilities, while audit trails should record all system activities to ensure accountability and detect suspicious behaviour.[29] To avoid data loss, regular backups must be performed and securely stored in offsite locations.[26]

From an ethical standpoint, patient privacy must be upheld through informed consent. Patients should be clearly informed about how their data will be collected, stored, and utilised.[27] Confidentiality agreements should be enforced for all staff handling sensitive information, and data minimisation practices must be adopted to prevent the collection of unnecessary personal details.[28] Additionally, transparent data retention and deletion policies should be in place, granting patients the right to request the removal or correction of their records.[27]

To mitigate the risk of misuse, third-party access to Aadhaar-linked dental data must be strictly regulated, requiring explicit patient consent for any sharing of information beyond the authorised government or forensic purposes.[26,28] By enforcing robust security measures and adhering to ethical standards, the Aadhaar-linked dental record system can guarantee confidentiality, privacy, and data integrity, while significantly enhancing the accuracy and efficiency of forensic identification processes.

Also, the Aadhaar-based dental record system integrates with the broader healthcare ecosystem, allowing interoperability with electronic health records (EHRs), medical databases, and government health initiatives. To make this happen, collaboration between the Indian government, dentistry schools, and dentists is required. There is formation of government organisation “National dental record maintenance organisation” (NDRMO) under “Unique Identification Authority of India” (UIDAI) and creating a nationwide dental record repository including registrations for all dental offices and institutes. Establishment of “Adhaar Dental Kendra” (ADK) improvises dental information based on antemortem proforma linking it to individuals Aadhaar numbers.[2]

The secondary function of the ADKs is to ensure regular updates of dental data of individuals in repository. Two modes can be used to deliver it: Firstly, dental schools and clinics are given special provisions to access the “National Dental Record Database” (NDRD) and update records of treated individuals daily, ensuring regular updates. Second, individuals can personally visit ADKs every 6 months to update their records. In both cases, it is mandatory for individuals who are not seeking dental treatment also to update their records every 6 months, promoting comprehensive and up-to-date dental information for all individuals in the system. The requirement of visiting ADKs every 6 months for record updates may initially seem burdensome and time-consuming. However, citizens need to recognise that this initiative serves their best interests and those of their loved ones.[4] Some limitations of this initiative would include that the Some limitations of this loss losprivacy of patients can be exposed or if someone makes changes in after updating. So, to avoid these consequences, there should be restriction of access to the digital platform after the dentist update to it; they should not be permitted to alter or update the person’s personal information, such as name, date of birth, and address,[4] but provision to change dental records should be there. It will be an important initiative if the government takes this forward so as to aid in forensic identification.

CONCLUSION

The majority of respondents are aware that dentists play an important role to forensic experts by maintaining dental records and think there is a need for a centralised digital platform in India. Dentists are crucial to this endeavour since teeth and dental structures can withstand harsh conditions. We recommend initiation of a central digital dental record platform in India to aid in forensic identification.

Ethical statement

The study has been approved by the Institutional Ethical Committee, KLE VK Institute of Dental Sciences, Belagavi with the Number.

Availability of data and material (data transparency)

The Data related to the study is available with the first author and will be provided if asked immediately.

Author contribution statement

The methodology, validation, investigation, analysis, collection of resources, draft was done by Dr Bidisha and Dr Gowsalya.

The conceptualization, analysis, writing and review, supervision and project administration was done by Dr. Punnya Angadi and Dr Alka Kale.

Consent to participate (include appropriate statements)

Informed Consent was obtained.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This work received no specific grant from any funding agency in the public, commercial or not for profit sectors.